Communication: We Can Do Better

Take a mental walk with me: You go to a restaurant and are greeted at the door then seated. The hostess asks for your drink order and you are surprised but you give it since you already know it. A few minutes later, a server arrives and walks you through the menu and asks for your drink order, again. You explain that you gave it to the hostess but so as not to be rude, you give it to the server as well. Drinks arrive and you order your meal. Before the food arrives, another person from the kitchen comes out twice to confirm your sides and the meat temperature. The food arrives late but is good. You would like to order desert but the server doesn’t return for a while despite you asking the hostess for help. When the server finally arrives, you decline desert and ask for the check. The server apologizes for the delay with “..it’s busy…I’m sorry” and fetches the check. It arrives from another person but isn’t quite correct. At this point you want to speak to the manager but fearing yet another delay, you just explain it to the person in front of you. An hour later you are walking out the door and the hostess says “hope to see you again soon.”

That’s not likely, right? You are not going to come back here when there are other options. The experience appears disorganized and the staff clearly do not communicate. Yet we so often rely on this kind of segmented, unorganized communication in the hospital. There is so much more at stake than steak, but we allow it.

As emergency departments grow in volume and physical size, quality communication between nurses and physicians become a casualty of war. We are at the “front lines”, we go to “battle” with every shift, but we have learned nothing from the rigid communication structure of the military. Electronic medical records force staff to document in layers, folders, and notes with non-intuitive structures. Physicians are not aware of what nurses are documenting and vice versa. Worse, we rarely see each other to communicate plans for patient care because we are disjointed in our workflows and tied to devices. And then there is the white flag of communication breakdown: the poor attitude. A physician makes snippy comments with every interruption or a nurse rolls eyes with every request. This response teaches us that the communication isn’t wanted, important, or relevant. So we teach each other that it is ok. Physicians ask the patient the same questions asked by the nurse, paramedics give report to the nurse not to a physician and the details are not relayed, nurses document a note but do not inform doctors of abnormalities they have noted, and staff lose their curiosity and their will to question when they notice a physician using an unusual treatment approach that may very well be due to an error. All of these represent small gaps in what is supposed to be a well oiled healthcare delivery machine with the patient at the center.

When we stop communicating due to barriers, physical or mental, the patient loses. It is no coincidence that my favorite type of patient is one who is in need of critical resuscitation. Those patients get an all call, all hands are on deck and every free staff member is eager to help, standing at the door ready for an order. The teamwork is overt and the common goal is united around the patient, now. Why can’t every encounter be that way? Wether it be a large physical space, a poorly designed EMR, a bad attitude, a lack of good communication devices, or all of these, we have to be vigilant in combating the barriers. Be aware of the difficulties and don’t settle for excuses. Work with your staff and director to find solutions and you will not just be happier and more productive, but you will make less errors and your patients will be safer in your hospital. That is, after all, what we are here to do.